|Year : 2022 | Volume
| Issue : 4 | Page : 168-173
Knowledge, attitude, and practice about painless local anesthesia injection techniques among pediatric dentists: An online cross-sectional survey
Sejal Jain, Seema Bargale, Bhavna Dave, Pratik B Kariya, Yash Shah, Shweta Dharmatti
Department of Pediatric and Preventive Dentistry, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
|Date of Submission||11-Oct-2022|
|Date of Decision||16-Nov-2022|
|Date of Acceptance||17-Nov-2022|
|Date of Web Publication||15-Dec-2022|
Dr. Sejal Jain
Department of Pediatric and Preventive Dentistry, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Various technologies and methods have been invented involving local anesthesia delivery with minimal child patient discomfort and reduced injection pain. These technologies include vibrotactile devices, computer-controlled local anesthesia delivery system (CCLADS), jet injectors, and nanotechnology. Aim: The aim of the current study is to assess the knowledge, attitude, and practice about painless local anesthesia injection technique among pediatric dentists in India. Materials and Methods: This study was an online cross-sectional survey consisting of 20 formulated questions about the various painless local anesthesia injection techniques. A total of 318 pediatric dentists participated in this online survey across India. The collected data were subjected to descriptive and Chi-square analysis. Results: Out of 318 responses received, 95% of pediatric dentists agreed that pain management is one of the most important aspects of child patient care. CCLADS and vibrotactile devices are among the most used painless injection techniques with 89.6% and 84.2%, respectively. Conclusion: The pediatric dentists were found to have good knowledge about the various painless injection techniques; however, these techniques were not adopted by many of them. There is a need to implement such painless techniques in order to reduce pediatric patient discomfort.
Keywords: Computer-controlled local anesthesia devices, electronic dental anesthesia, jet injections, pain anesthesia, vibrotactile devices
|How to cite this article:|
Jain S, Bargale S, Dave B, Kariya PB, Shah Y, Dharmatti S. Knowledge, attitude, and practice about painless local anesthesia injection techniques among pediatric dentists: An online cross-sectional survey. SRM J Res Dent Sci 2022;13:168-73
|How to cite this URL:|
Jain S, Bargale S, Dave B, Kariya PB, Shah Y, Dharmatti S. Knowledge, attitude, and practice about painless local anesthesia injection techniques among pediatric dentists: An online cross-sectional survey. SRM J Res Dent Sci [serial online] 2022 [cited 2023 Feb 6];13:168-73. Available from: https://www.srmjrds.in/text.asp?2022/13/4/168/363799
| Introduction|| |
Pain is described as a multifaceted entity influenced by psychological and physiological variables. Effective pain control during a child's dental visit often influences his or her behavior for the remainder of the appointment and subsequent dental visits. Consequently, pain management has become an important aspect of patient treatment. The injection of a local anesthetic agent is one among the most widely used for avoiding pain during dental therapy. Although this traditional method aids in liberating the pain caused by the treatment, the worry and fear of pain that the child develops remains a concern. According to Majstorovic and Veerkamp, 19% of 4–6-year-old children and 11% of 10–11-year-old children are diagnosed with needle phobia. Similarly, according to Vika et al., 6%–7% of children avoided dental treatment when the procedure involved an injection. Various technologies involving local anesthetic delivery with reduced injection pain have been introduced by researchers in recent years.
One of the most promising nonpharmacological approaches for painless local anesthesia is vibrotactile devices. The vibrotactile device lessens injection pain by providing a distraction in the form of physical sensations that interfere with pain signals, i.e., through gate control mechanism. These distraction stimuli are in the form of pressure, vibration, and micro-oscillation. Various vibrotactile devices available in the market are VibraJect, DentalVibe (DV), and Accupal. Sometime around the 1990s, the notion of delivery of local anesthesia through a computer-controlled system was born. The concept was to use computer technology to regulate the flow of local anesthetic fluid through the needle. Because discomfort during local anesthesia is caused by parameters such as pressure of the fluid and flow rate, the computer-controlled local anesthesia delivery (CCLAD) system delivers a consistent volume of local anesthesia solution at a predetermined pressure, resulting in less painful anesthetic delivery.
Jet injectors operate on the idea of generating enough pressure to drive a very fine column of anesthetic solution through the subcutaneous tissue by a very small opening using mechanical energy. This device is said to be better than traditional syringes since they are fast as well as provide easeful use, accompanied with minimal to no pain, faster drug absorption, less chances of infection at the site, and less tissue damage. Syrijet Mark II and MED-JET are the most popular jet injectors. Electrical nerve stimulation through the transcutaneous route is the basis for electronic dental anesthesia. The two main mechanism by which transcutaneous electric nerve stimulation (TENS) acts are the "gate control theory" and the "endogenous opioid system," wherein opioid peptides secreted by the pituitary and hypothalamus due to electrical stimulation join the cerebrospinal fluid. Epilepsy, cardiac pacemakers, older patients with senile dementia, and pregnancy are all contraindications to this device.
Nanotechnology has marked its application as a painless method for administering local anesthesia, especially in pediatric patients. When the colloidal solution having numerous micron-sized dental nanorobot particles encounters the gingival mucosa, chemical gradients and temperature differentials controlled by the dentist via a nanocomputer direct them through to the gingival sulcus, through lamina propria, and into the pulp without pain. These nanorobots are triggered after dental treatment to reinstate all nerve impulses and leave the tooth in a similar state. This technology provides excellent patient comfort, as well as fewer adverse impacts, as well as reduced patient anxiety. Even with all such evolutions, the knowledge of usefulness and awareness of these techniques still remains unanswered. The purpose of the current study is to assess the knowledge, attitude, and practice about painless local anesthesia injection technique among pediatric dentists.
| Materials and Methods|| |
This was a cross-sectional study conducted between August 2021 and January 2022. The study had been approved by the Sumandeep Vidyapeeth Institutional Ethics Committee (Date: July 31, 2021 Number: SVIEC/ON/Dent/SRP/21090). All the participants provided informed consent for their participation in the study. The study has been conducted with the help of the ethical standards given in the 1964 Declaration of Helsinki, as revised in 2013.
The number of participants needed for this study was calculated using Epi Info Software (by Centers for Disease Control and Prevention in Atlanta, Georgia) (version 7.2) which was determined to be 322 (pediatric dentists) to achieve more than 90% power for an α = 0.05.
Before starting with the electronic cross-sectional survey, the concurrent validity was assessed with 20 pediatric dentists. The purpose was to depict those with a greater degree of agreement among experts. The panel of experts recommended modifying the wording of some questions. Reliability of the questions was assessed by grouping similar questions and calculating the Cronbach's value (0.609). The questionnaire formulated for the study was validated by subject experts from the specialty of pediatric dentistry.
The online questionnaire consisted of 20 questions which were of close-ended type. The first section consisted of the consent form. The second section consisted of demographic data that involved gender, practice experience, and current working status. The third section consisted of questions depicting the knowledge, attitude, and practice about painless local anesthesia injection techniques among pediatric dentists. All the questions were marked mandatory to answer once the consent was approved. The response data were automatically tabulated from Google Forms. The current e-survey was conducted in accordance with CHERRIES guidelines.
The pediatric dentists in India were approached and provided with the questionnaire for an online open survey. The participants were informed through E-mail that the survey is voluntary and the information provided by them will be kept confidential. A reminder E-mail was sent after 2 weeks.
Statistical analyses were performed using IBM SPSS software (SPSS version 20.0; SPSS Inc., Chicago, IL, USA). The collected data were subjected to descriptive and Chi-square analysis with a significance level of P ≤ 0.05.
| Results|| |
A total of 318 pediatric dentists responded to the questionnaire. [Table 1] shows that 89% (P = 0.357) of the participants from the study were aware about the various painless local anesthesia injection techniques that are being used by pediatric dentists nowadays. When asked about the vibrotactile devices being utilized to deliver painless local anesthetic, 61.2% (P = 0.024) were aware about the mechanism behind it. 88.6% (P = 0.753) had good knowledge about the various vibrotactile devices available for use in the market.
|Table 1: Knowledge-based questions regarding painless local anesthesia techniques|
Click here to view
60.3% (P = 0.058) opted that the fluid pressure of injection device and the rate of flow of local anesthesia solution were the reason behind the action of CCLAD systems. 81.7% (P = 0.073) of participants agreed that CCLADS is highly preferred.
78.9% (P = 0.341) of the partakers had the correct knowledge about the working principle of jet injectors. Ninety-five percent (P = 0.602) of the participants were aware about the facts that worked in favor of this device. A noteworthy number of participants (81.4%, P = 0.099) knew about various jet injectors that are available nowadays.
91.8% (P = 0.608) of the participants were well versed with the working principles of exploratory data analysis. Ninety-five percent (P = 0.695) of pediatric dentists in the study were aware of the utilization of nanotechnology in delivery of painless local anesthetic.
In [Table 2], 95% (P = 0.774) of pediatric dentists agreed that pain management is the most important aspect of child patient care.
|Table 2: Attitude-based questions regarding painless local anesthesia techniques|
Click here to view
[Table 3] depicts the implementation of various painless local anesthesia delivery techniques by the participants. 84.2% (P = 0.785) of the participating population used vibrotactile devices. 89.6% (P = 0.635) of them agreed upon the use of CCLADS. 14.5% (P < 0.001) of the population applied jet injectors for painless local anesthesia whereas a significant amount of participants (85.5%) are not using jet injectors in their daily practice. A fairly notable number of participants do not use electronic dental anesthesia (91.2%) and nanotechnology (84.9%) in their current practice.
|Table 3: Practice-based questions regarding painless local anesthesia techniques|
Click here to view
| Discussion|| |
Recent development in the area of pain management in dentistry has led to introduction of newer and better delivery devices accompanied with advancements in injection techniques. Their ultimate target is to allow the clinicians to have the best treatment approach, associated with negligible injection pain, essential for managing anxiety in pediatric patients. The current study agreed with the same, i.e., managing pain is an important part of child patient care.
Factors leading to pain and discomfort during local anesthesia injection are needle penetration along with tension created because of tissue expansion during the infiltration of anesthetic fluid. The vibrations created by vibrotactile device relieve pain of the needle prick along with reducing infiltration pain by physically enabling the spreading of anesthetic fluid. As large proprioceptive A-beta fibers adapt rapidly to stimulation but are readily re-activated by a change in stimulus, the pulsed vibration of the vibrotactile device maintains the A-beta fiber activation and closure of the gate for perception of small pain fibers.
This study showed that a large proportion of pediatric dentists were aware of the various vibrotactile devices. Vibrating devices are attached to the syringe to reduce pain during injection through a gate control mechanism, some of the examples are the syringe micro vibrator and VibraJect which have been introduced in recent years with mixed results., In our study, 61.2% of pediatric dentists were aware about the concept of vibrotactile devices. According to a study conducted by Dhanapriya et al. where they studied the visual analog score of local soft tissue upon injecting local anesthesia under the impact of vibration, they found that injections with vibration led to lower pain scores by patients which justifies the reason why 84.2% of pediatric dentists are implementing this device in their practice. Ching et al. investigated the effect of the vibrotactile device on adolescent patients where one-half of the patients received injections with the vibrotactile device turned on and the other half received injections with the device turned off (control group). All injections were supraperiosteal (infiltration) injections and the vibrotactile device significantly reduced the pain from these injections. DiFelice et al., from their study, hypothesized that DV3 (vibrotactile device) would reduce pain/discomfort caused by injections and reduce the time necessary for complete anesthesia. These studies showed that the better performance of these devices is the reason why a significant number of pediatric dentists are using vibrotactile device as portrayed by the outcomes of the current study.
According to studies by Dempsy Chengappa and Prashanth and Sharma et al., CCLADS is a device which is more accepted by child patients in addition to producing less disturbing behavior, and also known to be successfully applied for a number of procedures in pediatric dentistry which gives grounds for the result in our current study which shows that 89.6% of pediatric dental professionals choose to implement this technique in their dental practice. This study also highlighted that a significant amount of pediatric dentists were aware about the working and usefulness of CCLADS. The currently available CCLADS can regulate the volume of anesthetic fluid, pressure along with speed at which the solution is to be delivered, thus leading to reduction in tissue distortion and painful experience. This mechanism of action is well understood by the pediatric dental professionals as 60.3% of them knew the working of this device. According to a meta-analysis done by Pozos-Guillén et al., CCLADS was perceived with less pain than normal injection. Dempsy Chengappa et al.[ 12] reported that injections with CCLADS had reduced painful experience. Chavhan et al. in their study observed that children displayed better behavior using Wand system, when they compared Wand with conventional method. According to a study by Patini et al., it was reported that there were markedly lesser pain scores while using Wand. According to Giannetti et al., 91% of patients referred a positive experience (Frankl scale); 94% reported a positive evaluation (Wong–Baker Facial Image Scale): 100% effectiveness on deciduous teeth and 70% on permanent teeth on application of CCLADS. All these studies have laid out the reason why the current study shows a significant number of dentists practicing with this device.
The needleless jet injector, which works on the phenomenon of pressure dynamics, provides an alternative technique for inducing local anesthesia that is safe and comfortable for patients. The needleless jet injection delivers local anesthesia without subjecting the patient to the unpleasant experience of having to face "the needle," thereby enabling him/her to develop a more positive approach toward the dental treatment. According to a study by El Tawil and El Dokky, lower pain perception was seen when INJEX was used. In spite of the success of this device, this study portrays that only 14.5% of pediatric dentists are using this device. According to a study by Hameed et al., the patient acceptance rate was observed to be 83%. Altan et al. through their study have reported more preference for the jet instrument, which is in contradiction to the present study results where majority of the pediatric dentists are not preferring this device and thus require more awareness.
TENS has been proposed as a more comfortable and helpful alternative to traditional local anesthetic procedures for relieving anxiety., To describe the working mechanism of TENS in pain control, various theories have been suggested, namely gate control theory, endorphin release theory, and the theory of serotonin release. This study claimed that 91.8% of study population were aware about this mechanism. A study by Siddiqui et al. said that TENS proved more efficient than topical lignocaine at reducing pain from injections that require deeper tissue penetration. Recent studies performed by Dhindsa et al. and Varadharaja et al. portrayed that when doing minor pediatric dental treatments, TENS was as effective as 2% lignocaine. Despite the success depicted by all these studies, electronic dental anesthesia was only being used by 8.8% of pediatric dentists according to the findings of the current study.
The function of nanotechnology in anesthesia includes delivery of analgesic colloidal suspension containing many functional dental nanorobot particles. They control nerve impulses by blocking the nerve endings. In the present study, pediatric dentists have agreed that nanotechnology has proven to have many benefits. It promises to provide greater patient comfort and minimal patient anxiety. In spite of such impressive benefits, nanotechnology has not found a strong ground in pediatric dentistry, as stated by the current study.
| Conclusion|| |
Almost everyone who took part in the study understood the importance and working of various techniques for painless local anesthesia. Vibrotactile and CCLADS were among the most used methods. There is a need for more awareness and implementation of these techniques.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Angelo Z, Polyvios C. Alternative practices of achieving anaesthesia for dental procedures: A review. J Dent Anesth Pain Med 2018;18:79-88.
Majstorovic M, Veerkamp JS. Relationship between needle phobia and dental anxiety. J Dent Child (Chic) 2004;71:201-5.
Vika M, Raadal M, Skaret E, Kvale G. Dental and medical injections: Prevalence of self-reported problems among 18-yr-old subjects in Norway. Eur J Oral Sci 2006;114:122-7.
Sriram K, Selvarasu K. Adjunct techniques for painless intraoral local anesthesia – A systematic review. Drug Invent Today 2018;10:2761-8.
Singh N, Agarwal S, Bhagchandani J, Chandra P, Gaur A. Painless anesthesia: A new approach. J Dentofac Sci 2013;2:49-55.
Umaiyal MP, Dhanraj M, Ganapathy MD. Advances in dental local anaesthetic delivery devices – A review. Int J Sci Dev Res 2021;6:397-403.
Shahidi Bonjar AH. Syringe Micro Vibrator (SMV) a new device being introduced in dentistry to alleviate pain and anxiety of intraoral injections, and a comparative study with a similar device. Ann Surg Innov Res 2011;5:1.
Saijo M, Ito E, Ichinohe T, Kaneko Y. Lack of pain reduction by a vibrating local anesthetic attachment: A pilot study. Anesth Prog 2005;52:62-4.
Dhanapriya D, Kumar DN, Srinivasan D, Babu J. A comparative study on pain encountered with a simulator vibrotactile device assisted la administration, with topical la technique and conventional technique. Int J Appl Dent Sci 2019;5:3-6.
Ching D, Finkelman M, Loo CY. Effect of the DentalVibe injection system on pain during local anesthesia injections in adolescent patients. Pediatr Dent 2014;36:51-5.
DiFelice MG, Vandewalle KS, Maller SC, Hancock RH. Effects of a vibratory device on pain from anesthetic injections. Compend Contin Educ Dent 2014;35:246, 248, 250-1 passim.
Dempsy Chengappa MM, Prashanth AK. Evaluation of efficacy of computer-controlled local anaesthetic delivery system versus traditional injection system for minor pediatric surgical procedures in children. Med J Armed Forces India 2022;78 Suppl 1:S89-95.
Sharma SS, Sharma A, Saravanan C. Newer local anaesthetic drugs and delivery systems in dentistry – An update. J Dent Med Sci 2012;1:10-6.
Sreenivas A, Raj AS, Puthenpurackal VR, Haneef T, Pillai GR, Jose D, et al
. Pain perception in different injection techniques in paediatric dentistry: An original research. Eur J Mol Clin Med 2021;7:3056-61.
Pozos-Guillén A, Loredo-Cruz E, Esparza-Villalpando V, Martínez-Rider R, Noyola-Frías M, Garrocho-Rangel A. Pain and anxiety levels using conventional versus computer-controlled local anesthetic systems in pediatric patients: A meta-analysis. J Clin Pediatr Dent 2020;44:371-99.
Chavhan P, Jawdekar A, Deshpande S, Chandak S, Niswade G, Bhondey A. Comparison of pain perception during the administration of local anaesthesia with computerized delivery system (WAND) and conventional technique in pediatric dental procedure using visual analogue scale – A randomised controlled trial. Clin Epidemiol Glob Health 2020;8:224-8.
Patini R, Staderini E, Cantiani M, Camodeca A, Guglielmi F, Gallenzi P. Dental anaesthesia for children – Effects of a computer-controlled delivery system on pain and heart rate: A randomised clinical trial. Br J Oral Maxillofac Surg 2018;56:744-9.
Giannetti L, Forabosco E, Spinas E, Re D, Murri Dello Diago A. Single tooth anaesthesia: A new approach to the paediatric patient. A clinical experimental study. Eur J Paediatr Dent 2018;19:40-3.
Brunton PA, McLean M, Vedagiri S, McKeage J, Ruddy B, Weatherly K, et al.
Jet injection needle-free dental anaesthesia: Initial findings. J Dent 2022;122:104165.
Mckeage JW, Loch C, Zwirner J, Hammer N, White DE, Ruddy BP, et al
. Controllable jet injection of dental local anaesthetic. IEEE J Transl Eng Health Med 2021;9:1-8.
El Tawil SB, El Dokky NA. Effect of jet injection (INJEX) on pain perception among a group of pediatric dental patients. Egypt Dent J 2018;64:1933-9.
Hameed MS, Kumar S, Charanya C, Muthalagu M, Anitha M. Comparison of jet injection technique with conventional injection technique in patients undergoing endodontic therapy. Contemp Clin Dent 2021;12:28-31. [Full text]
Altan H, Belevcikli M, Coşgun A, Demir O. Comparative evaluation of pain perception with a new needle-free system and dental needle method in children: A randomized clinical trial. BMC Anesthesiol 2021;21:301.
Gunasekaran S, Babu G, Vijayan V. Local anaesthesia in pediatric dentistry: An overview. J Multidiscip Dent Res 2020;6:16-21.
Veneva ER, Belcheva AB. Local anesthesia in pediatric patients – A review of current and alternative methods, devices and techniques. Folia Med 2018;60:381-8.
Li C, Shi Z, Glenny AM. Electronic dental anaesthesia for managing pain during dental procedures. Cochrane Database Syst Rev 2018; 2:1-5.
Siddiqui A, Patel HJ, Bhutia ET, Kade K, Chincholi R, Patil A. Comparative evaluation of transcutaneous electronic nerve stimulation and topical anesthesia in reduction of pain perception during administration of local anesthesia in pediatric dental patients. Ann Rom Soc Cell Biol 2021;25:1793-8.
Dhindsa A, Pandit IK, Srivastava N, Gugnani N. Comparative evaluation of the effectiveness of electronic dental anesthesia with 2% lignocaine in various minor pediatric dental procedures: A clinical study. Contemp Clin Dent 2011;2:27-30.
] [Full text]
Varadharaja M, Udhya J, Srinivasan I, Sivakumar JS, Karthik RS, Manivanan M. Comparative clinical evaluation of transcutaneous electrical nerve stimulator over conventional local anesthesia in children seeking dental procedures: A clinical study. J Pharm Bioallied Sci 2014;6:S113-7.
Florez FL, Pathak Y, Preuss C. Orally delivered nanoparticle drug-delivery systems for dental applications and their systemic toxicity. Nanobiomaterials in Clinical Dentistry, 2nd ed. Elsevier.2019; 595-616
Kasimoglu Y, Tabakcilar D, Guclu ZA, Yamamoto-Nemoto S, Tuna EB, Ozen B, et al
. Nanomaterials and nanorobotics in dentistry: A review. J Dent Indones 2020;27:77-84.
[Table 1], [Table 2], [Table 3]